Refusion of anterior cerebral artery after aneurysm clipping--a case report

Herein, we are describing an unusual case suffering from a left anterior cerebral artery aneurysm (A1). Both the anterior cerebral arteries were supplied by the left internal carotid artery as was found in digital substraction angiography (DSA) preoperatively. The postoperative angiograms revealed that left anterior cerebral artery was supplied from the left internal carotid artery and the right anterior cerebral artery by the right internal carotid artery respectively. This finding of cerebral angiograms is interesting and rarely mentioned in the literature. Its hemodynamic change and pathogenesis were unclear and different to that of the coronary circulation, ischemic change of gut and skeletal muscle. The causes may include: 1) vasospasm at the anterior communicating artery after manipulation at surgery; 2) desiccation or shrivelling the adjacent artery by intraoperative electrocoagulation; 3) occlusion the anterior communicating artery by the wing of clip. 4) the deprivation of the blood flow from the left internal carotid artery after totally or partially narrowing left A1 by an aneurysm clip. The redistribution of blood volume in the previously hypoplastic right anterior cerebral artery and decreased caliber of the left anterior cerebral artery (A1) are likely playing a role in this case.     

Paradoxical cerebral embolism during fibrinolysis therapy in deep vein thrombosis and pulmonary embolism

A 37-year-old woman with increasing dyspnoea over several months suddenly developed severe ortho- and tachypnoea as well as cyanosis of the lips and acrocyanosis. Pulmonary angiography revealed massive bilateral pulmonary emboli with a systolic pulmonary artery pressure of 75 mm Hg. Phlebography demonstrated a thrombotic occlusion of the deep veins of the left leg extending to the distal femoral vein. Thrombolysis treatment was started via an indwelling pulmonary artery catheter (500,000 IU urokinase and 10,000 IU heparin as bolus, then 1 mill. IU urokinase and 1,000 IU heparin per hour). After two hours an incomplete left-sided paresis occurred (involving ocular and facial muscles, dysarthria, left arm and left leg) and the thrombolytic infusion was stopped. But cerebral computed tomography (CT) did not demonstrate any intracerebral haemorrhage. The heparin infusion was restarted (partial thromboplastin time between 70 and 90 s). CT examinations during the next few days showed the development of an ischaemic infarction in the distribution of the right medial cerebral artery. Angiography demonstrated occlusion of the right internal carotid artery. The diagnosis of a paradoxical embolus was supported by easy cardiac catheter passage through a patent foramen ovale. Subsequent pulmonary angiography demonstrated a thrombus-free pulmonary arterial circulation with a normal pulmonary arterial pressure. There was gradual and extensive regression of the incomplete hemiparesis.     

Agenesis of the internal carotid artery associated with an aneurysm of the anterior communicating artery

We report a case of agenesis of the internal carotid artery which was revealed by a subarachnoid hemorrhage. Angiography showed a ruptured aneurysm of the anterior communicating artery and unilateral absence of the left internal carotid artery. Both the left anterior and middle cerebral arteries were perfused from the right carotid artery via the anterior communicating artery. Absence of the left carotid canal was proved on bone CT. Such an association is discussed. An hemodynamic stress on a congenital defect of the cerebral arterial wall could be the origin of the aneurysm development.     

Internal carotid artery occlusion related to seat belt shoulder strap: report of two cases

Two cases of traumatic internal carotid artery occlusion probably related to the seat belt shoulder strap are reported. Case 1. A 20-year-old woman was driving and was struck on the right front side of her car by another car. There were neither bruises, abrasions on her neck, nor weakness in her extremities. About 4 hours later, she developed left hemiplegia, and CT scan taken on the following day revealed low density areas in the capsulostriatal area on the right. The right carotid angiography revealed occlusion of the internal carotid artery about 3 cm distal to the bifurcation. Case 2. A 43-year-old man was driving and was struck on the front of his car by a hard iron railing. He sustained a sternum fracture, but there was no disturbance of consciousness or paresis of the extremities. His neck was unremarkable externally. About 50 days later, he developed left hemiplegia. CT scan and MRI revealed a massive infarction in the distribution of the right middle cerebral artery territories. The carotid angiography revealed occlusion of the right internal carotid artery about 3 cm distal to the bifurcation. In each cases, the driver was wearing a three-point shoulder seatbelt when the car was struck on the front or on the right front. Previous experimental studies have revealed in these situations the neck is flexed right anteriorly, and then quickly overextended left posteriorly. The overextension of the neck probably injured the intima of the internal carotid artery ipsilateral to the shoulder fixed in the seatbelt, resulting in the subsequent occlusion by a thrombus.     

Angioplasty of the occluded internal carotid artery

PURPOSE: To review patients who have presented with acute strokes from a middle cerebral artery occlusion in whom in addition to the middle cerebral artery thromboembolus, an internal carotid artery occlusion has been present, and in whom angioplasty of these totally occluded internal carotid arteries has bee n successful. METHODS: We reviewed retrospectively our experience in treating a cute stroke patients with intracranial, intraarterial urokinase. Six of 27 patients had internal carotid artery occlusions in addition to middle cerebral artery occlusions. Two patients presented with spontaneous carotid dissections for wh ich no further intervention from the ipsilateral internal carotid artery was attempted. In the remaining four internal carotid artery occlusions secondary to atherosclerotic disease, standard guide wires and catheters were negotiated across the level of the internal carotid artery occlusion, which expedited intracranial catheterization for thrombolysis. Subsequently, angioplasty of the internal carotid artery was performed. RESULTS: All four occluded internal carotid arteries could be traversed. No new neurologic deficits occurred. No vascular injuries occurred. No deaths occurred. Four- to 6-month follow-up showed all four internal carotid arteries remained patent. CONCLUSION: In acute occlusions of the internal carotid artery from atherosclerosis, the occluded vessel can sometimes be recanalized with low morbidity. In addition, endovascular access to the intracranial circulation can be expedited by using the recanalized internal carotid artery.     

Surgical treatment of common carotid artery occlusion

Eight patients with common carotid artery (CCA) occlusion underwent bypass with saphenous vein to either the carotid bifurcation (five), the internal carotid artery (two), or the external carotid artery (one). Indications included ipsilateral transient ischemic attack (two), recent nondisabling hemispheric stroke (two), and transient nonhemispheric cerebral symptoms (two). Two asymptomatic patients with CCA occlusion and contralateral internal carotid stenosis underwent prophylactic revascularization prior to planned aortic surgery. There were no perioperative strokes, occlusions, or deaths. Late ipsilateral stroke occurred in two patients, and one patient had a single transient ischemic attack after 2 years. The four patients with preoperative transient cerebral ischemia experienced relief of their symptoms. Duplex ultrasound is an accurate screening modality for distal patency. Collateral filling of the internal or external carotid artery can usually be demonstrated after aortic arch or retrograde brachial contrast injection. End-to-end distal anastomosis after endarterectomy eliminates the original occlusive plaque as a potential source of emboli. The subclavian artery is preferred for inflow on the left. The CCA origin is easily accessible for inflow on the right. Bypass of the occluded CCA is safe and may be effective in relieving transient cerebral ischemic symptoms, although long-term ipsilateral neurologic sequelae may still occur.     

Cerebral infarction associated with nephrotic syndrome in a young adult: a case report

We report a 19-year-old man who developed a cerebral infarction in the territory of the anterior choroidal artery and showed a hypercoagulable state and nephrotic syndrome after diarrhea and appetite loss. He had suffered from nephrotic syndrome from the age of three and had been treated for five years. MR-angiography showed an occlusion originating in the right internal carotid artery. The right anterior and middle cerebral arteries were imaged from the left internal carotid artery via the anterior communication artery. He showed symptoms of left hemiparesis, agnosia, loss of activity, anasarca and left hypacusis following his clinical course, but had recovered from all but left hemiparesis following medical treatments including steroid therapy. The histologic finding by a renal biopsy revealed focal glomerulosclerosis. In this case, we considered that when he was in a hypercoagulable state and had a second attack of nephrotic syndrome because of inflammation and dehydration due to diarrhea and appetite loss, his hypercoagulable state grew worse, and he then developed a cerebral infarction. When one see a patient with nephrotic syndrome, one should be attentive to the possibility of a complication of cerebral infarction.     

Agenesis of internal carotid artery associated with aneurysm of anterior communicating artery (author's transl)

A case of agenesis of the left internal carotid artery with an aneurysm of the anterior communicating artery was reported in detail. The patient was a 48-year-old man who had an episode of subarachnoid hemorrhage about 10 years ago. This time left heminumbness and motor weakness of the left lower extremity occured and he was brought our hospital. Right common carotid angiography, left retrograde brachial serial angiography and aortography demonstrated an agenesis of the left internal carotid artery, an aneurysm of the anterior communicating artery, tortuous megadolic hobasilar artery and anomalies on the circle of Willis such as absence of supra optic portion of the right anterior cerebral artery, and large left posterior communicating artery. We confirmed latter findings by operation. After successful neck clipping of the aneurysm, his clinical findings were remarkably improved.     

A case of multiple cerebral arterial thrombosis due to congenital protein C deficiency]

We report a 49-year-old man who had right hemiparesis and motor aphasia. A computed tomography revealed hypodense areas in the left frontal subcortex. A cerebral angiography demonstrated occlusion of the left distal internal carotid artery and both anterior cerebral arteries, as well as stenosis of the left internal carotid artery at the cervical portion. The second angiogram obtained a month later showed no changes. The diagnosis of atherothrombotic cerebral infarction was established on the basis of clinical profile and angiographic findings. Protein C activity and antigen levels were reduced to approximately one half of the normal level in the patient and his brother. The patient had no other risk factors for stroke. Protein C deficiency has been considered one of the risk factors for thrombotic diseases. Venous thrombosis is the most common clinical manifestation, whereas arterial thrombosis is relatively rare. It is generally believed that arterial ischemic stroke associated with protein C deficiency occurs with embolic mechanism, and atherothrombotic infarction is extremely rare. This is the first report suggesting the possibility that protein C deficiency can cause cerebral thrombosis.     

Immunoaffinity column as cleanup tool for a direct competitive enzyme-linked immunosorbent assay of cyclopiazonic acid in corn, peanuts, and mixed feed

PURPOSE: Atherothrombotic occlusion of the cervical internal carotid artery (ICA) without collateral flow is one of the most critical forms of acute ischemia. We report the results of urgent thrombolytic treatment of patients with major stroke in this clinical category. METHODS: Clinical findings and outcome in 33 patients were investigated. All patients had suffered a major stroke, with a score of 24 or higher on the NIH Stroke Scale on admission. Ischemic abnormalities were not detected on initial CT studies. Diagnoses were made at angiography, and patients were treated by intravenous or intraarterial local thrombolysis within 6 hours of stroke onset. RESULTS: Recanalization was accomplished in eight patients with intraarterial local thrombolysis; four of these patients had a good clinical outcome. Two factors characteristic of those whose treatment was successful were dramatic improvement of symptoms after partial recanalization achieved within 3 hours of onset and stabilized improvement after subsequent percutaneous transluminal angioplasty or carotid endarterectomy for residual atherosclerotic stenosis at the ICA origin. CONCLUSION: The results of this study suggest that urgent intraarterial local thrombolysis may be a successful treatment method for some patients in this critical clinical category if the treatment can be accomplished within 3 hours of ictus and followed by either angioplasty or endarterectomy for residual stenosis.     

Saccular aneurysms of meningeal artery: case report

OBJECTIVE AND IMPORTANCE: A rare observation of double saccular aneurysms of the meningeal artery is presented. CLINICAL PRESENTATION: This 22-year-old man was referred to the Neurosurgical Institute with a suspicion of an aneurysm of the anterior communicating artery. Bilateral angiography of the carotid arteries was performed 1 week after the subarachnoid hemorrhage, but the aneurysms were not visualized. Routine angiography of both carotid arteries and selective studies of the left vertebral artery were performed again, and angiography of the right carotid artery revealed an aneurysm. The patient's neurological state at the time of admission was normal. Fundoscopic examination revealed papilledema and conjunctival injection of the left eye. INTERVENTION: The patient was treated using a right pterional approach. One aneurysm had caused spontaneous subarachnoid hemorrhage. The aneurysms were removed using a direct approach, with histological examination of dura matter fragment containing both aneurysms. The results of the patient's 2-week follow-up examination were normal. Follow-up angiography of the right carotid artery showed absence of the aneurysm with a clip on the branch of meningeal artery. CONCLUSION: Saccular aneurysms of the meningeal artery can be manifested by subarachnoid hemorrhage, and intradural arterial aneurysms are similar to saccular cerebral vessel lesions structurally.     

Daily dosimetric quality control of the MM50 Racetrack Microtron using an electronic portal imaging device

Dissection of cerebral arteries as a cause of stroke is rarely recognized in children. Two patients with stroke due to extracranial carotid artery dissection are reported. A 7-year-old girl with a 2-week history of right arm chorea had a left basal ganglia infarct and is receiving haloperidol for persistent chorea. The second patient, a 15-year-old boy, developed aphasia and right hemiparesis a day before admission during a football game without obvious trauma. He had a large left middle cerebral artery infarct and died of cerebral edema and herniation. We believe that strokes due to arterial dissection are more common than currently recognized, partly because of a lack of history of trauma, and suggest that cerebral artery dissection be considered as an etiology of childhood strokes. Greater awareness of arterial dissection as a cause of stroke and availability of noninvasive techniques like magnetic resonance angiography should result in a more accurate diagnosis and improved prognosis in these patients.     

Predicting the effect of carotid artery occlusion during carotid endarterectomy: comparing transcranial doppler measurements and cerebral angiography

BACKGROUND and PURPOSE: We correlated the mean transcranial Doppler blood flow velocity (FVm) during carotid endarterectomy with the functional collateral pathway(s) documented by angiography. METHODS: Three patient groups were established: group 1 was dependent on the anterior communicating artery, group 2 on the anterior communicating artery and ipsilateral posterior communicating artery, and group 3 on the ipsilateral posterior communicating artery. Continuous middle cerebral artery FVm and electroencephalographic monitoring were performed in 45 patients during carotid endarterectomy. RESULTS: Clamped FVm was lowest in group 3 at 17+/-9 cm/s versus 36+/-16 and 33+/-11 cm/s for groups 1 and 2 (P<0.01). FVm values in groups 1 and 2 were similar. There was significant cerebral arterial vasodilation in group 3 patients on the basis of a pulsatility index of 0.38+/-0.15. The maximum FVm after clamp release was similar among the 3 groups. Normalized blood flow velocity 1 minute before release of the clamp was increased from the minimum flow velocity after clamping only in group 1 and 2 patients. CONCLUSIONS: The ipsilateral posterior communicating artery is a minor collateral pathway during acute carotid occlusion that contributes little to the collateral flow if there is a functional anterior communicating artery. Collateral flow through the middle cerebral artery is not recruited during occlusion in group 3 patients. The reperfusion FVm transient is independent of the primary collateral pathway. Documentation of functional collateral pathways on the basis of Doppler or angiographic examination may be advantageous in future studies since it can provide the basis for comparison among studies.     

Role of transcranial Doppler and stump pressure during carotid endarterectomy

BACKGROUND AND PURPOSE: The aim of our study was to clarify the pathophysiology of perioperative cerebral complications during carotid endarterectomy in our series. METHODS: By means of transcranial Doppler ultrasonography and stump pressure measurement, we monitored 112 patients who underwent carotid endarterectomy under general anesthesia for symptomatic or asymptomatic severe carotid stenosis. RESULTS: Of 18 patients who underwent carotid endarterectomy with intra-arterial shunt, 2 (11.1%) developed an ischemic stroke. Of the other 94 patients, one suffered a nucleocapsular hemorrhage and 5 had cerebral ischemic complications. In these 5 patients, the duration of clamping was significantly longer (mean +/- SD, 16.4 +/- 1.1 versus 12.7 +/- 2.6 minutes; P = .0019), and the decrease of middle cerebral artery mean velocity on clamping was significantly greater (mean +/- SD, 56.4 +/- 4.9% versus 28.8 +/- 20.2%; P = .0031), while stump pressure was not significantly different. Microembolic signals were recorded in 70 patients (62.5%) and were not associated with cerebral ischemic complications. The 7 patients who developed cerebral ischemic complications had a significantly higher percentage of stenosis in the contralateral internal carotid artery (mean +/- SD, 82.0 +/- 17.8% versus 29.3 +/- 36.4%; P = .0018). CONCLUSIONS: The results of our study suggest that the major complications of carotid endarterectomy may be due to hemodynamic factors. Stump pressure alone is not a reliable indicator of hemodynamic changes that predict cerebral ischemia. Particulate microembolism may cause more subtle changes in cerebral parenchyma, but further studies are needed to clarify this point.     

Occlusion of the cervical internal carotid artery due to a dog bite wound: case report

A rare case of traumatic occlusion of the carotid artery at the neck caused by a dog bite is reported. A 10-year-old boy presented delayed onset of left hemiparesis after a dog-bite wound in the right neck. CT scan revealed a cerebral infarction in the right basal ganglia, and IV-DSA disclosed complete occlusion of the right internal carotid artery at the neck. The patient was treated conservatively and his left hemiparesis improved, but impaired visual acuity remained on the right side. Repeated IV-DSA 12 days later showed recanalization of the right internal carotid artery. The mechanisms of the traumatic occlusion of the internal carotid artery were discussed with reference to the literature.     

Symptomatic recurrent carotid stenosis and aneurysmal degeneration after endarterectomy

BACKGROUND: Aneurysmal degeneration of a carotid reconstruction was not recognized until the patient, who was known to have recurrent carotid artery stenosis, had a thromboembolic stroke. This sequelae of carotid endarterectomy is a serious complication, associated with a high morbidity and mortality rate. This review was conducted to establish the risk of transient ischemic attack and stroke for patients found to have recurrent carotid stenosis associated with aneurysmal degeneration of the carotid artery after endarterectomy. METHODS: A case is reported, and 100 literature references of aneurysmal degeneration of the carotid artery after endarterectomy were reviewed. RESULTS: False aneurysm from anastomotic disruption was the most common presentation identified in the cases reviewed. Nineteen of the patients had a significant neurologic event; however, three (50%) of six patients with aneurysm and recurrent carotid artery stenosis had a transient ischemic attack or stroke. CONCLUSIONS: The incidence of neurologic symptoms is markedly increased when recurrent carotid artery stenosis is associated with carotid aneurysm. During postoperative surveillance after endarterectomy, the identification of recurrent carotid artery stenosis requires evaluation for aneurysmal degeneration of the carotid artery with duplex scanning. These patients are at significant risk for transient ischemic attack and stroke. This rare complication merits operative repair.     

Increase of cerebral blood flow and improvement of brain motor control following spinal cord stimulation in ischemic spastic hemiparesis

A 64-year-old man had an ischemic stroke in the left parietotemporal cortical-subcortical areas. He developed a severe right spastic hemiparesis and dysphasia. An angiographic study showed left internal carotid artery occlusion and right internal carotid artery stenosis. A right internal endoarteriectomy was performed without any clinical improvement. After 1 year the patient was a candidate for cervical spinal cord stimulation (SCS) for the treatment of his spastic hemiparesis. An epidural electrode (Medtronic Sigma 3483) was positioned at the cervical level, mediodorsal to the cord. Clinical and neurophysiological studies (surface polyelectromyography, PEMG, for evaluation of brain motor control) were performed before and after 7 days of SCS (0.2 ms, 80 c/s, intensity for paresthesiae, continuous mode). A transcranial Doppler (TCD) study of both middle cerebral arteries (MCA) at rest and during SCS was performed on two occasions. SCS was followed by improvement of voluntary movement, decrease of spasticity and better endurance. The clinical findings were confirmed by the PEMG recordings. TCD examination showed an increase of flow velocities on both the right MCA (+43%) and the left MCA (+130%) during SCS. Such a TCD pattern, suggesting an increase of cerebral blood flow (CBF) during SCS, was reproducible. This case confirms efficacy of SCS in the treatment of ischemic hemiparesis and the increase of CBF following cervical SCS in man. The marked increase of CBF, particularly evident on the ischemic side, may play a role in mediating the improvement of motor control in our patient together with a possible arousal of the so-called 'sleeping neurons' of the penumbra zone.     

Differential diagnosis in dementia

The results of an autopsy of a 78-year-old female patient with an occluded of the right internal carotid artery after a traffic accident are reported. She presented with consciousness disturbance, right conjugate deviation, left hemiparesis and left pathological reflex. Evidence of right skull and clavicular fractures seemed to suggest that severe hyperextension of her neck associated with contralateral lateral flexion had stretched her carotid artery. Although she was treated with antiplatelet therapy, her cerebral swelling due to right global infarction progressed and she died due to bilateral cerebral herniation three days after injury. The autopsy disclosed right dissecting carotid artery occlusion and subadventitial dissection was revealed histologically. When a hematoma dissect the media and adventitia of the carotid artery wall, the outer wall weakens and may dilate without narrowing the lumen of the carotid artery. In this case, the vessel occlusion was considered to be due to a primary intramural hematoma which developed and subsequently ruptured through the intima into the vessel lumen. Early diagnosis and treatment are necessary for improving the prognosis of this disease entity. A patient with poor colateral flow, such as in this case, will show a rapid progression of cerebral infarction. It is best to consider surgical treatment in this case if the other traumatic lesions are able to tolerate surgery.     

Middle cerebral artery dissection

A 12-year-old girl had minor head trauma, with resultant mild headache, one day prior to onset of an apparently generalized tonic clonic seizure, right hemiparesis and dysphasia. A cranial CT scan showed evidence of a left middle cerebral artery infarct. Despite ventilation, fluid restriction, mannitol, thiopental infusion and intracranial pressure monitoring she deteriorated and died. Autopsy demonstrated dissection of the left middle cerebral artery with an intact internal carotid artery and no evidence of vasculitis. Middle cerebral artery dissection in children is very rare. Most reported cases are diagnosed at autopsy. The pathogenesis of cerebral artery dissection may include preceding minor head trauma or exertion and this should be sought for in the history.     

Endoluminal repair of internal carotid artery aneurysm: a feasible but hazardous procedure

PURPOSE: The aim of this study was to report the repair of an aneurysm of the internal carotid artery using the endoluminal method. METHODS: A 70-year-old male patient noted a swelling in the right side of his neck 22 years after endarterectomy of the right internal carotid artery. Duplex ultrasound confirmed the clinical diagnosis of aneurysm of the internal carotid artery. Further investigation included contrast-enhanced computed tomographic (CT) scanning and carotid angiography performed via a retrograde femoral approach. The aneurysm contained thrombus and was 3 cm in diameter and in length. It extended superiorly from a point 0.5 cm above the carotid bifurcation to a point estimated to be 2 cm from the base of the skull. Repair of the aneurysm was undertaken using the endoluminal method. A self-expanding endograft 8 mm in diameter and 4 cm in length was introduced through a 12F sheath in the common carotid artery. An on-table completion angiogram of the right-sided extracranial carotid arteries and the intracranial internal carotid artery and branches was obtained. RESULTS: The completion angiogram and postoperative CT scan confirmed exclusion of the aneurysm sac from the circulation. The patient awoke from anesthesia with complete paralysis of the left arm. Recovery of movement commenced 1 hour later. A brain CT scan demonstrated the event to be an embolic stroke. Strength had returned by 7 days. Function of the arm was good 1 month after operation, but coordination for fine movements was lacking. At the 6-month follow-up, good arm function was maintained. A duplex ultrasound scan demonstrated not only continued exclusion of the aneurysm sac but occlusion of the endograft, also. CONCLUSIONS: Endoluminal repair of aneurysms of the internal carotid artery is feasible but carries the risk of major morbidity as a result of peripheral embolization and early occlusion of the endograft.